Management of Spinal Cord Injuries

A Guide for Physiotherapists

Lisa Harvey

• Publisher: Churchill Livingstone
• Year: 2008
• ISBN:
  9780702036156
• Topic: Medicine
• Subtopic: Physiotherapy, Physical Medicine & Rehabilitation

Combining 25 years of clinical, research and teaching experience, Dr Lisa Harvey provides an innovative 5-step approach to the physiotherapy management of people with spinal cord injury. Based on the International Classification of Functioning, this approach emphasises the importance of setting goals which are purposeful and meaningful to the patient. These goals are related to performance of motor tasks analysed in terms of 6 key impairments. The assessment and treatment performance of each of these impairments for people with spinal cord injury is described in the following chapters:

• training motor tasks
• strength training
• contracture management
• pain management
• respiratory management
• cardiovascular fitness training

Dr Harvey develops readers' problem-solving skills equipping them to manage all types of spinal cord injuries. Central to these skills is an understanding of how people with different patterns of paralysis perform motor tasks and the importance of differentmuscles for motor tasks such as:

• transfers and bed mobility of people
• wheelchair mobility
• hand function for people with tetraplegia
• standing and walking with lower limb paralysis

This book is for students and junior physiotherapists with little or no experience in the area of spinal cord injury but with a general understanding of the principles of physiotherapy. It is also a useful tool for experienced clinicians, including those keen to explore the evidence base that supports different physiotherapy interventions.

Section 1

The bare essentials

Outline

Chapter 1: Background information

Chapter 2: A framework for physiotherapy management

Chapter 1

Background information

Contents

Motor, sensory and autonomic pathways

The ASIA assessment of neurological deficit

Common patterns of neurological loss with incomplete lesions

Upper and lower motor neuron lesions

Prognosis

Impairments associated with spinal cord injury

Skin management

Psychological well-being

Spinal cord injury and traumatic brain injury

Aging with spinal cord injury

The spinal cord travels within the vertebral canal of the spine and is vital for conveying and integrating sensory and motor information between the brain and somatic and visceral structures. A spinal cord injury impairs motor, sensory and autonomic functions, the implications of which are profound and lead to an array of secondary impairments.

The term ‘spinal cord injury’ is used to refer to neurological damage of the spinal cord following trauma. In most developed countries, the incidence of spinal cord injury is between 10 and 80 cases per million per year.^1,2 Approximately half of all spinal cord injuries occur in people aged under 30 years.^3–6 The typical person with spinal cord injury is male, aged between 15 and 25 years; only about 15% of spinal cord injuries affect females and only 18% affect people over 45 years.³ Obvious exceptions to these demographics occur in natural disasters. For example, in the Pakistan earthquakes of 2005 the majority of spinal cord injuries (estimated to be over 1500) were in young women and children.

The most common causes of spinal cord injury are motor vehicle and motor-bike accidents, followed by falls.^3,7 Work-related injuries are also common, as are injuries from sport and water-based activities. In some countries the incidence of spinal cord injury from gun, stab or war-related injuries is high. Spinal cord lesions can also be due to disease, infection and congenital defect.

Over 55% of all spinal cord injuries are cervical; the remainder are approximately equally divided between thoracic, lumbar and sacral levels.^8,9 The most common level of injury is C5, followed by C4, C6 and T12, in that order.¹⁰ A spinal cord injury in the cervical region affects all four limbs, resulting in tetraplegia (also called quadriplegia). Spinal cord injuries in the thoracic, lumbar or sacral region affect the lower limbs and result in paraplegia. Most spinal cord injuries do not involve transection or severing of the spinal cord.^11,12 Rather, the cord remains intact and the neurological damage is due to secondary vascular and pathogenic events, including oedema, inflammation and changes to the blood–spinal cord barrier.^13,14

The extent of damage to the spinal cord is highly variable and, consequently, a spinal cord injury can prevent the transmission of all or just some neural messages across the site of the lesion.⁹ In some patients the only sign that part of the spinal cord has been preserved is very slight movement or sensation below the level of the injury. For other patients there may be extensive preservation of motor and sensory pathways enabling them to walk almost normally. Partial preservation of the spinal cord is more common following cervical, lumbar and sacral injuries than thoracic injuries. It is also more common today than 20 years ago because of advances in retrieval, emergency and acute management reducing secondary neural damage (see Figure 1.1).¹⁵

Figure 1.1 Prevalence of different types of spinal cord injuries in developed countries. Prevalence refers to the number of people living with SCI. Reproduced from Martin Ginis KA, Hicks AL: Exercise research issues in the spinal cord injured population. Exerc Sport Sci Rev 2005; 33:49–53, with permission of Lippincott Williams & Wilkins.

Motor, sensory and autonomic pathways

The vertebral column consists of seven cervical, 12 thoracic, five lumbar, five sacral and four coccygeal vertebrae, although the sacral and coccygeal vertebrae are fused. Emerging from the spinal cord are 31 pairs of anterior and posterior nerve roots: eight cervical, 12 thoracic, five lumbar, five sacral and one coccygeal. At each level an anterior (ventral) pair of nerve roots carries motor nerves and a posterior (dorsal) pair of nerve roots carries sensory nerves. The anterior and posterior roots join to form two spinal nerves, one on either side of the spine, which then exit the vertebral canal through the intervertebral foramina. Once outside the intervertebral foramina they form peripheral nerves.¹⁶

While there are eight pairs of cervical spinal nerves there are only seven cervical vertebrae. This disparity occurs because the first pair of cervical spinal nerves exits above the first cervical vertebra just below the skull. However, the eighth pair of cervical spinal nerves exits below the last cervical vertebra (see Figure 1.2).¹⁷

Figure 1.2 The spinal cord, illustrating relationship between vertebrae and nerve roots. Reproduced from Parent A: Carpenter’s Human Neuroanatomy, 9th edn. Baltimore, Williams & Wilkins, 1996, with permission of Lippincott Williams & Wilkins.

Motor pathways

Upper and lower motor neurons connect the motor cortex and muscles. The upper motor neurons originate within the motor cortex and then travel down the spinal cord within the corticospinal tracts. These tracts are also called pyramidal tracts. Approximately 85% of upper motor neurons cross over to the contralateral side in the brainstem and then travel within the lateral corticospinal tract. The other 15% cross within the spinal cord at the level they terminate and are carried within the medial corticospinal tract. The cervical upper motor neurons are centrally located within the corticospinal tract and the lumbar and sacral neurons are peripherally located (see Figure 1.3). This explains patterns of neurological loss seen with certain types of incomplete spinal cord injuries where the peripheral rim of the spinal cord is undamaged (see p. 11). There are also other complex motor pathways contained within the extrapyramidal system.

Figure 1.3 Cross-section of the spinal cord illustrating the corticospinal and spinothalamic tracts, and the posterior (or dorsal) columns.

The upper motor neurons synapse in the spinal cord with anterior horn cells of l...